Long Term Care

Management of people with heart failure in the UK has shortcomings in screening, continuity of care, and medication doses, which disproportionally impact women and older people; so according to a study led by Nathalie Conrad and Kazem Rahimi of The George Institute for Global Health at the University of Oxford, UK, publish May 21 in PLOS Medicine.

Findings suggest that screening and follow-up are sub optimal, and these problems could be due; so at least in part, to poor record-keeping in primary care; also inadequate information exchange between hospitals and primary care. Heart failure is common affecting about 2% of the population in high income countries and can lead to disability and death. Effective treatment usually involves a complex process of investigations; so step-wise initiation of medicines, and dose-adjustments, which can sometimes be challenging to follow.

Electronic health records

In the past decade, the UK has introduce programs to evaluate and improve heart failure management in primary and secondary care; but patients’ care trajectories across different healthcare settings have not been studied. In this retrospective study, Rahimi and colleagues use electronic health records; so from 93,074 people who were diagnose with heart failure in the UK between 2002 and 2014 to investigate the medical care they receive from diagnosis to 1 year later.

The authors examine five indicators of care: (i) diagnosis setting (inpatient or outpatient), (ii) post-hospitalization follow-up in primary care, (iii) diagnostic investigations, (iv) prescription of essential drugs, and (v) drug treatment doses. The study suggests that patients were more likely to be diagnose with heart failure; so in hospital than by their general practitioner, receive insufficient follow-up after hospital discharge; also were prescribe medications at insufficient doses.

The average daily dose prescribe was below guideline recommendations (42% for ACE-I or ARB; so 29% for beta-blockers in 2014) and remaine largely unchange beyond the first 30 days after diagnosis; hence despite guideline recommendations to regularly up-titrate doses.  Rates of outpatient diagnoses and follow-up in primary care were low; also even decline over time (from 56% in 2002 to 36% in 2014, RR 0.64 [0.62, 0.67] and from 20% to 14%, RR 0.73 [0.65, 0.82], respectively).

Health services design

Gaps in care were more common in women, individuals older than 75 years; also to some extent in socioeconomically deprived individuals. The authors call for additional research to explore the reasons behind these disparities; so saying that further improvements are likely to require broader approaches to health services design that support appropriate care at every level of the patient journey.

In an accompanying Perspective, Nicholas Mills and colleagues at the University of Edinburgh, UK; they discuss the need for high-quality implementation science (the study of strategies to integrate; also embed research advances into clinical practice) and large-scale analysis of routinely collect healthcare data.

They argue that real time collation of healthcare data across primary and secondary care; also robust methodologies to evaluate changes in clinical practice and policy; are essential to successfully overcome these disparities and gaps in care. To ensure the highest standards of patient center care and best resource allocation, Mills and colleagues argue for a linked; so anonymize healthcare informatics platform for sharing data between care; so settings that is granular enough to facilitate meaningful evaluation of current practice.